Parastomal hernias are a common complication of intestinal ostomies, occurring in 35-50% of patients. Recent studies have explored prophylactic mesh placement during primary stoma formation to prevent parastomal hernias, finding a significant reduction in hernia rates compared to no mesh. However, the quality of evidence is still limited. Ongoing research focuses on techniques like stapled mesh reinforcement to further establish the benefits of prophylactic mesh in preventing these hernias.

1. A.Odobašić, Ad.Odobašić, F.Odobašić
University Clinical Center Tuzla - Bosnia and Herzegovina
Bosnian- Herzegovinian American Academy of Arts and Sciences
9th BHAAAS days in B&H; Teslic, May 25-28, 2017.
Parastomal hernia in colorectal cancer:
to prevent or when and how do the surgery?

2. What is ostomy?

3. Ostomy = an artificial opening in the
abdominal wall, which connects a hollow
viscus (bowel, urinary tract) to the
outside enviroment / to divert faeces or
urine to the exterior which is collected in
an external appliance

4. Intestinal ostomy = Opening of the
intestinal tract into abdominal wall

5. Types of intestinal ostomies
Duration:
Temporary
Permanent
Anatomical location:
Jejunostomy
Ileostomy
Colostomy

7. Types of intestinal ostomies
Reconstruction:
End
Loop
Double Barrel (Mickulicz)

11. Double - barrel Colostomy
When creating a double – barrel colostomy, the
surgeon divides the bowel completely. ( 2 ostomy
besides each other and separate from each other)
Each opening is brought to the surface as a
separate ostomy
Proximal – end = end stoma ( secrets stool),
needs a drainage bag.
Distal – end = mucous fistula ( secretes mucus)
Temporary ostomy

14. Specific complications of ostomy
Skin excoriation
Prolapse
Bleeding
Retraction
Stenosis
PARASTOMAL HERNIA ........

16.  Parastomal Hernia-the Achilles Heel of a Permanent
Colostomy
Suk-Hwan Lee
Department of Surgery, Kyung Hee University School of
Medicine, Seoul, Korea
J Korean Soc Coloproctol 2011;27(4):163-164

17. PARASTOMAL HERNIA - PSH
 Definition:
 Parastomal hernia (PSH) is a protrusio of abdominal
contents through a weakness in the abdominal wall
at the site of the previous hole made for delivering
the stoma.
 Incidence:
 Parastomal hernia occurs in 35%-50% of patients who
have had a intestinal stoma formed

18. Incidence of PSH
 The true incidence of PSH is difficult to assess and
varies widely depending on:
 the length of follow-up
 the type of ostomy
 use of radiological imaging (computed tomography
[CT] or ultrasonography) in diagnosis.

19. Incidence of PSH
 Today, ostomy creation is a common procedure with an
estimated 120,000 new stomas created each year .
 Prevalence of up to 800,000 patients in the United
States living with a stoma

20. Diagnostic
 Physical examination
 Ultrasound
 CT scan

21. Parastomal hernia: clinical and
radiological definitions. A Jänes, L Weisby, LA
Israelsson. Hernia, 2010

22. Parastomal hernia: clinical and
radiological definitions. A Jänes, L Weisby, LA
Israelsson. Hernia, 2010

24. Risk factors for PSH formation
 Smoking
 Obesity
 Diabetes
 Malnutrition
 Immunosuppression
 Patients with conditions that chronically increase
intra-abdominal pressure, including cough and COPD
 Advanced liver disease with ascites...

25. Surgical technique for ostomy
 Several technical factors have been purported to
influence PSH formation, including: emergency
surgery; trephine size, shape and location; route of the
loop of bowel that forms the stoma (transperitoneal or
extraperitoneal); portion of bowel that forms the stoma
(colostomy or ileostomy); and the stoma conformation
(loop or end).
 Although individual technical factors that predispose to
PSH formation have been identified, there is no
consensus on the optimal technique for stoma
formation.

26. The rate of PSH for:
 Loop colostomy - 0 to 30,8%
 End colostomy – 4,0 to 48,1%
 Loop ileostomy – 0 to 6,2%
 End ileostomy – 1,8 to 28,3%

27. Classification of PSH

28. Surgical treatment
 Simple Fascial Repair - high recurrence rates ranging
from 10 to 76%
 Stoma Translocation - with recurrence rates of 33% to
76%
 Mesh repair – recurrence rates less than 20% for both
synthetic and biologic meshes
 Onlay mesh placement, retromuscular mesh placement,
open intraperitoneal mesh placement with either the
keyhole or Sugarbaker technique
 Laparoscopic mesh placement – Keyhole technique,
Sugarbaker, Sandwich technique

29. Keyhole / Sugarbaker

30. Position of mesh

31.  Surgical techniques for parastomal hernia repair: a
systematic review of the literature
 BME Hansson et al. Annals of Surgery, 2012
 The use of mesh in parastomal hernia repair significantly
reduces recurrence rates and is safe with a low overall
rate of mesh infection.

33. Prophylactic mesh use during primary stoma formation
to prevent parastomal hernia
B Cornille, S Pathak, IR Daniels, NJ Smart Royal Devon and Exeter NHS Foundation Trust, UK.
Ann R Coll Surg Engl 2017; 99: 2–11
 METHODS A systematic search was performed using PubMed,
Embase™ and the Cochrane Library to identify randomised
controlled trials that analysed placement of prophylactic mesh
versus no mesh at time of initial surgery. Meta-analysis was
performed using random effects methods.
 RESULTS A total of 506 studies were identified by our search
strategy. Of these, 8 studies were included, involving 430 patients
(217 mesh vs 213 no mesh). Prophylactic mesh placement resulted
in a significantly lower rate of PSH formation (42/217 [19.4%] vs
92/213 [43.2%]) with a combined risk ratio of 0.40 (95% confidence
interval [CI]: 0.21–0.75, p=0.004). Placement of prophylactic mesh
did not result in increased peristomal complications (15/218 [6.9%]
vs 16/227 [7.0%]) with a combined risk ratio of 1.0 (95% CI: 0.49–
2.01, p=0.990).

34.  CONCLUSIONS Prophylactic placement of mesh at primary
stoma formation may reduce the incidence of PSH, without an
increase in peristomal complications.
 However, the overall quality of the randomised controlled
trials included in the meta-analysis was poor, and should
prompt caution regarding the applicability of the findings of
the individual studies and the meta-analysis to every-day
practice.

36. Stapled Mesh stomA Reinforcement Technique (SMART) in the
prevention of parastomal hernia: a single-centre experience
Z. Q. Ng, P. Tan, M. Theophilus, Hernia June 2017, Volume 21, Issue 3, pp 469–475
 The aim of this retrospective analysis was to evaluate the
outcomes of Stapled Mesh stomA Reinforcement Technique
(SMART) in terms of parastomal hernia occurrence rate and
mesh-related complications.
 METHODS All patients operated with an abdominal perineal
resection or Hartmann’s procedure with SMART from November
2013 to March 2016 were included. Patient demographics,
operative details and stoma-related symptoms were collected.
Patients were examined clinically by the medical team and also
reviewed independently by a specialist stoma care nurse for signs
of stoma-related complications. As part of oncological follow-up,
CT scans were available for review for evidence of parastomal
herniation.

37.  RESULTS 14 patients (mean age 76 years) were included in the
analysis. All the SMART cases were successfully completed
with no intraoperative or immediate post-operative
complications. No cases of mesh-related complications such as
infection, immediate stomal prolapse, stenosis, retraction,
stomal obstruction, mesh erosion or fistulation were observed.
No mesh removal was required. There were two cases of
parastomal hernia detected on CT scan. Both cases have
remained asymptomatic no intervention was required at this
stage. Median follow-up was 24 months.
 CONCLUSION Our medium-term experience has demonstrated
the efficacy of SMART in the reduction of parastomal hernia
occurrence. With appropriate learning curve, parastomal
hernia can be prevented.

39.  Preventing parastomal hernias with systematic
intraperitoneal specifically designed mesh
 Raquel Conde-Muíño, José-luis Díez, Alberto Martínez, Francisco Huertas,
Inmaculada Segura and Pablo PalmaB . BMC SURGERY 2017, 17:41
 Methods Data were prospectively recorded. A specifically
designed mesh made of polyvinyl fluoride with central conduit
(Dynamesh IPST®) was fixed using an intra-peritoneal onlay
technique. Safety was evaluated by means of surgical data and
frequency of mesh-related complications, efficacy by the rate
of parastomal hernias.

40.  Results Thirty-four patients were included in the study. Three
of them died before a year of follow up (not related to the
stoma), so they were excluded. The other 31 patients (11
women and 20 men) were prospectively followed up after
different pathologies resulting in a permanent colostomy.
Twelve months after surgery CT-Scan imaging revealed two
(6.4%) parastomal hernias, one of them already clinically
suspected. During the follow up, 29% of the patients (n = 9)
developed another type of hernia (incisional, inguinal or both).
In five patients (16.1%) a light stomal retraction of the
otherwise slightly prominent ostomy was observed. Median
clinical follow-up was 17.5 months (range 12–34).
 Conclusion Prophylactic parastomal mesh placement might be
a safe and effective procedure with a potential to reduce the
risk of parastomal hernia. Routine use of this technique should
be further analysed.

41. Parastomal Hernia-the Achilles Heel of a Permanent
Colostomy
Suk-Hwan Lee
Department of Surgery, Kyung Hee University School of Medicine, Seoul,
Korea
J Korean Soc Coloproctol 2011;27(4):163-164

42. Summary
With such a high incidence of PSH and recent success with
mesh repair, much attention has been given to
prophylactic mesh placement at the time of primary stoma
formation, especially for permanent colostomy after an
abdominoperineal resection (APR).
Nevertheless, the only technique that has been examined
in detail in prospective randomised controlled trials (RCTs)
is the use of prophylactic mesh at the time of stoma
formation.
Hernia prevention with prophylactic mesh placement at
the time of stoma creation may be the continued focus of
future research.